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AL <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site andro'r :111-NRYIENT <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Maikeet Kaur <br />ID PROPERTY / BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT business owner <br /> <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />DATE: 08/05/2024 <br />111 New Facility 1=1 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />SUBWAY <br />Site Address <br />1601 S LOWER SACRAMENTO RD <br />City <br />LODI <br />State <br />CA <br />ZIP <br />95242 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for 0 Consultation <br />Operating Permit <br />0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments , i <br />Csftsi; A3 gL c ;- I ili--, clitc-Li,le t,(-- <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner <br />,ii;Kligatz., <br />0 Contractor 0 Architect <br />l'Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />MALKEET <br />Last name <br />KAUR <br />If contractor, indicate type and license number <br />Address <br />1601 S LOWER SACRAMENTO RD <br />City <br />LODI <br />State <br />CA <br />ZIP <br />95242 , <br />Phone <br />559-567-5055 <br />Phone Email <br />pb31food@yahoo.com <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner El Facility Contact 0 Property Owner 0 Contractor 0 Arptict _ <br />in 14 YMEN1 <br />and €CI.lf, <br />i Et First Name Last name If contractor, indicate type <br />Address City State ZIP A <br />fi <br /> I . <br />U6 02 In zu24 <br />Phone Phone Email SAN Jo A <br />NV/RoQUiN COutvr <br />Accepted By Assigned To --. Linked FA ID- 0-3ce.2../.._ <br />Date c,-,- -s- --)-1- <br />PE <br /> ( <br />Fee <br />\-3-2-- - <br />Record Number. pa4.0e 3 7 / <br />0 Cash 0 Check # Confirmation # igcqg 1 16,6- <br />Payment de__ <br />Received By <br />Rev 07/10/2024 W05‘-\\SSL\